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HomeMy WebLinkAboutBuilding Permit #493-2016 - 266 BLUE RIDGE ROAD 10/20/2015s'e,,�w •",FD 16IJ/9 //s BUILDING PERMIT TOWN OF NORTH ANDOVER � APPLICATION FOR PLAN EXAMINATION j Permit No#: I� Date Received Date Issued: t''0 � li _ IMPORTANT: Applicant must complete all items on this page f � LOCATION � f _ Print PROPERTY OWNER ' Print 100 Year Structure yes no ;MAPPARCEL: 64Z- ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other El Septic ❑Well ❑Floodplain ❑Wetlands ❑Watershed District ❑ Water/Sewer OWNER: Name: Addressc-1010 i Contractor Name Email Address: Z Supervisor's Con! UESCRIPTiON OF WORK TO BE PERFORMED: Wication - Please Type or Print Clearly 19 � 1 Phone: YS 7- 9) License: Exp. Date: r Ifs j Home Improvement License: Alai, Exp. Date: 141 tlIh ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $_��� FEE: $ rl�� Check No.: �0 g2 11Receipt No.: f54 NOTE: Persons contracting wit1ymmfe ed contractors do not have access to u . fi Sianature of Aaent/Owner�- Sianature of contractor Location No. � J 3 `U' Date / b ? 0 /,�-I TOWN OF NORTH ANDQVER Certificate of Occupancy $ Building/Frame Permit Fee $Al7 f -D Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # `� Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On COMMENTS CONSERVATION COMMENTS HEALTH V COMMENTS Signature Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE.DEPARTMENT - Temp Dumpster on site yes no Located at' 12.4,,Main Street Fire Department signature/date a q . COMM€N1"S Dimension Number of Stories:________ Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No, DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A —F and G min.s10041000 fine Doc.Building Pennit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Building Permit Revised 2014 O = "O _ O � _; • o r N r N < m � en 1 � - CD nCD O O ,, rt CL C M rt = Z p' =r —I Oh N ,Oy �D' 0T). TI .+• O O rt Q M -+ =4S cn M CD W n O y p 0CD CD O. N CD D S cam. N COL. o -.0 rt CD WCD -0FL, � -i O �_� • o c to cQ 0 • OONO" O N j '— � U) 0rt3 O SS" • -• U) Dm a N Q O O O CL N Q CD CO) N CD M CD• N W CD CD r ..a fl1 CD N ' i v:�� *#fit' OI 00 0 p y pa, 0 =rfAr C E• CD N s s c -h = rt Pogo S v_ CD C CD •a s K o 00' � rt O � Q.. t/1 N O Nrr 3 0 L �p (D O C T M O O- T Ol VI < n X O C aq rz- m ,O O C Q U S O UQ S O � O_ r? N 0 G O CL Cl) M v a M z (Av N O N M r n m M 0m �ro c W z m -� C r z r^ M 3 z W O v o m Cl) M � C Cl) � O � Cl) 0 � Z � v z Z'0.: O = "O _ O � _; • o r N r N < m � en 1 � - CD nCD O O ,, rt CL C M rt = Z p' =r —I Oh N ,Oy �D' 0T). TI .+• O O rt Q M -+ =4S cn M CD W n O y p 0CD CD O. N CD D S cam. N COL. o -.0 rt CD WCD -0FL, � -i O �_� • o c to cQ 0 • OONO" O N j '— � U) 0rt3 O SS" • -• U) Dm a N Q O O O CL N Q CD CO) N CD M CD• N W CD CD r ..a fl1 CD N ' i v:�� *#fit' OI 00 0 p y pa, 0 =rfAr C E• CD N s s c -h = rt Pogo S v_ CD C CD •a s K o 00' � rt O � Q.. t/1 N O Nrr 3 0 L �p (D O co 7 N T M O O- T Ol VI < n X O C aq T 3 d ,O O C Q T 5' S O UQ S O � O_ r? N 0 G O CL M v a M z (Av N O N M r n m M �ro c W z m -� C r z r^ M 3 ' W O v o m 14 iiext step Living. home energy soLutions This agreement Is made by and among Nicole Ehrie 266 Blue Ridge Rd North Andover, MA 01845 Site ID: 420574 1. DESCRIPTION OF WORK TO BE PERFORMED Next Step Living, Inc. ("NSL") 21 Drydock Avenue, 2nd floor Boston, MA 02210 phone: (866) 867-8729 16 -Sep -15 NSL will perform or cause to be performed the following work on the customer's address above, in a professional manner and in accordance with the terms of this Contract, including the attached recommendationstwork order describing the work in detail (the "Work") which are incorporated herein by reference. Pricing reflected below may be subject to adjustments in program pricing and offerings and is guaranteed for 30 days from the date the Contract is printed,. Work Location: Attic Flat Perform Air Sealing at Estimated 62.5 CFM50 Per Hour 14 $85.00 Hr $1,190.00 Work Location: Attic Flat Attic Stair Cover Thermal Barrier with Carpentry 1 $237.65 Each $237.65 Hatch: Thermal Barrier Polyiso 2 inch (Attic) 1 $60.00 Each $60.00 Damming 82 $2.05 Lnft $168.10 Vent bath fan to roof flapper 2 $118.75 Each $237.50 Propavent 2' or 4' 100 $2.00 Each $200.00 Attic Floor Open Blow Cellulose 4" 1,432 $1.13 sgft $1,618.16 Work Location: Knee Wall Install 2" Thermal Barrier Polyiso on Kneewall 27 $3.50 sgft $94.50 Li It Nicole Ehrie (Sep 18, 2015) Customer Signature �G�er� I%rNT/ Elizabeth Venuti (Sep 16, 2015) NSL Signature 100% Airsealing Incentive up to Program Max $1,020.00 75 % Weatherization Incentive up to Program Max $1,961.93 Air Sealing Remainder as 75 % Weatherization Incentive up to Program Max $38.07 Estimated Annual Energy Savings from the Above Improvements $184.00 Sep 18, 2015 Date 16 Sep 2015 Elizabeth Venuti Date Name of NSL Representative A1280246 The Terms of this Agreement are contained on both sides of this page Next Step Living o 21 Drydock Avenue o 2nd floor o Boston, MA 02210 a (866)867-8729 - inquiry@nextsteplivinginc.com o www.nextsteplivine.com TERMS OF AGREEMENT 420574 3. PROPOSED START DATE AND COMPLETION SCHEDULE NSL will contact customer to schedule the Work at a mutually agreeable time, subject to the availability of subcontractors or materials, or to delays attributable to the weather or other events beyond NSL's control. 4, CONTRACTOR REGISTRATION Massachusetts law requires home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by wrifing to: Office of Consumer Affairs and Business Regulation, Ten Park Plaza, Suite 5170, Boston, MA 0211K 617-973-8700. 5. PERMITS NSL will be responsible for obtaining any necessary permits as the Customer's agent. Customers who secure their own permits or deal with an unregistered contractor will be excluded from the Guaranty Fund provisions of the Home Improvement Contractor Law. 6. PERFORMANCE OF THE WORK AND CHANGES 6.1 NSL will not commence the Work prior to signing this Agreement and transmittal of a copy of Agreement to the Customer 6.2 This Agreement may be supplemented, amended, or modified only by the mutual agreement of the parties. No supplement, amendment, or modification of this Agreement shall be binding unless it is in writing and signed by all parties. 6.3 At times, our weatherization team discovers situations in the structure during the course of the Work that indicates a risk for a health or safety concern for residents. Such concerns can include but are not limited to ventilation, potentially hazardous materials such as mold or asbestos, or structural concerns. In the case of health or safety concerns being identified, NSL reserves the right, per section 9.2 of this contract, to communicate concerns to the Customer and halt work until such concerns have been addressed. 6.4 The rebates and incentives available from the Mass Save' Home Energy Services Program and amounts due from the Customer are based on the best estimate of the situation in the structure by the NSL home energy advisor. However, at times our weatherization team discovers situations in the home during the course of the Work that impact the availability of rebates and incentives from the Mass Save Program. In such situations, NSL will communicate such changes to the Customer, including any impact on amount the Customer would be expected to pay for the Work. The Customer will have the option to remove from the Contract the work elements that need adjustment, or setup a separate contract for performing the adjusted work. 6.5 NSL represents and warrants to the Customer that (a) the materials and equipment fumished under this Agreement will be of good quality and new, (b) that the Work will be free from defects, and (c) that the Work will conform with the description of the Work described in Paragraph 1. 6.6 NSL may determine in the course of pre -installation Technical Review that modifications are necessary to the scope of Work in order to ensure professional quality of the installation. In the event of such modifications, NSL will request a written modification of the Agreement to be signed by all parties. In the event that Customer and NSL cannot agree on the modification, the Agreement may be terminated by either party. 7. INSURANCE AND REGISTRATION NSL represents and warrants to the Customer that it has a valid Home Improvement Contractor Registration (No: 162111) and the necessary insurance required by applicable law and normally maintained by prudent contractors in NSL's field, including, but not limited to, Workers Compensation Insurance for all employees who will perform the Work. 8. QUALITY OF WORK NSL agrees that the Work will be performed in a good and workmanlike manner, and that NSL will repair and replace, at its own expense, and promptly upon Customer's request, any defects in workmanship and materials provided by NSL which appear up to one year after completion of the Work or within any longer period as permitted or required under applicable law, provided NSL has received final payment as provided herein. 9. PRE-EXISTING CONDITIONS & PROPERTY PROTECTION 9.1 NSL shall not be responsible for any damages as a consequence of the Work performed in the home due to pre-existing conditions. These conditions include but are not limited to poorly fastened or broken drywall, moisture damage, non -code construction, cracked or fragile siding or shingles, old pipes and fittings, rotting wood, etc. 9.2 NSL reserves the right not to perform Work upon the discovery of asbestos, mold, or any other potential health risk to the Customer. In this event, the Customer is responsible for remedying the at -risk situation, including any necessary removal of hazardous materials and all bills for services to date shall be paid immediately. Work cannot resume until remediation is complete. 9.3 While NSL will make best efforts to protect any property of the Customer, it is the Customer's responsibility to remove or protect, including dust protection, any personal property including the home itself. NSL will not be responsible for damages to or losses of any of the above mentioned property not properly protected prior to the commencement of the Work. 10, GENERAL PROVISIONS. 10.1 NSL reserves the right, the extent permitted by applicable law, to have, file or maintain a mechanic's or material men's lien, or to file a notice of intention to lien, and to take any other steps to perfect and enforce such a lien, if Customer fails to pay NSL as provided herein. 10.2 This Agreement shall be construed in accordance with the laws of the Commonwealth of Massachusetts. 10.3 This Agreement forms the complete integrated agreement between NSL and Customer. The parties represent and warrant that in executing this Agreement, they are not relying on any representations, warranties or terms other than as expressly contained herein. This Agreement supersedes all prior agreements between the Customer and Contractor and may not be altered absent a subsequent written agreement signed by both parties. 11. ENERGY BENEFITS. The Sponsoring Utility Company (the Utility) is entitled to 100% of the energy benefits associated with all Energy Conservation Measures, excluding the value of energy cost savings by the Customer, but including all rights to all associated ISO -NE Energy, Capacity and Reserves Products. NSL agrees to provide the Utility with such further documentation as the Utility may request to confirm the Utility's ownership of such benefits and Products. 12. NOTICE CONCERNING SPONSORSHIP. 12.1 Customer understands and acknowledges that NSL is not an agent, vendor or sub -vendor of The Sponsoring Utility Company (the Utility) with respect to the installation of an energy efficiency measures. In the event of the failure of an energy conservation device to perform as expected, Customer's sole recourse is to Contractor and not to RISE Engineering (RISE) or to the Utility. The Utility and its operating companies shall not maintain, remove or perform any work whatsoever on the energy conservation measures installed. 12.2 Customer understands and acknowledges that their participation in the Mass Save Home Energy Services Program is voluntary and that they have consented for Contractor to install the proposed energy conservation measures. 12.3 Customer agrees that it shall not hold RISE, the Utility, their affiliates or operating companies liable for Contractor's to perform its obligations under this agreement, for failure of the energy conservation measures to function, for any damage to Customer's Premises caused by Contractor or for any and all damages to property or injury to persons caused by the energy conservation measures. 13. LIMITED TIME OFFER. The prices and incentive offered in this Contract are subject to change in accordance with The Sponsoring Utility Company Mass Save Home Energy Services Program offers. 14. CONTRACT CANCELLATION Under Massachusetts law, you may cancel this agreement If it has been signed by a party thereto at a place other than an address of the seller, which may be his main office or a branch thereof, provided you notify the seller in writing at his main office or branch by ordinary mail posted, by fax, or by e-mail sent or by delivery, not later than midnight of the third business day following the signing of this agreement. next step Living, home energy solutions This agreement Is made by and among Nicole Ehrie 266 Blue Ridge Rd North Andover, MA 01845 Site ID: 420574 1. DESCRIPTION OF WORK TO BE PERFORMED Next Step Living, Inc. ("NSL") 21 Drydock Avenue, 2nd floor Boston, MA 02210 phone: (866) 867-8729 16 -Sep -15 NSL will perform or cause to be performed the following work on the customer's address above, in a professional manner and in accordance with the terms of this Contract, including the attached recommendations/work order describing the work in detail (the "Work") which are incorporated herein by reference. Pricing reflected below may be subject to adjustments in program pricing and offerings and is guaranteed for 30 days from the date the Contract is printed.. Work Location: Attic Flat Recessed Light Cover (Not Rebate Eligible) 4 $31.25 Each $125.00 Estimated Annual Energy Savings from the Above Improvements $18.00 2. PAYMENT, CUSTOMER agrees to pay NSL for the work as follows: Payment #1: $50.00 Additional Payments and Final Invoice: $75.00 Ad fism Nicole Ehrie (Sep 18, 2015) Customer Signature 'C[i�Az,e7l Ve-,g7,- Elizabeth Venuti (Sep 16, 2015) NSL Signature Sep 18, 2015 Date 16 Sep 2015 Elizabeth Venuti Date Name of NSL Representative A1280246 The Terms of this Agreement are contained on both sides of this page TERMS OF AGREEMENT 3. PROPOSED START DATE AND COMPLETION SCHEDULE NSL will contact customer to schedule the Work at a mutually agreeable time, subject to the availability of subcontractors or materials, or to delays attributable to the weather or other events beyond NSL's control. 4. CONTRACTOR REGISTRATION Massachusetts law requires home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to Office of Consumer Affairs and Business Regulation, Ten Park Plaza, Suite 5170, Boston, MA 02116.617.973.8700. 5. PERMITS NSL will be responsible for obtaining any necessary permits as the Customer's agent Customers who secure their own permits or deal with an unregistered contractor will be excluded from the Guaranty Fund provisions of the Home Improvement Contractor Law. 6. PERFORMANCE OF THE WORK AND CHANGES. 6.1 NSL will not commence the Work prior to signing this Agreement and transmittal of a copy of Agreement to the Customer. 6.2 This Agreement may be supplemented, amended, or modified only by the mutual agreement of the parties. No supplement, amendment, or modification of this Agreement shall be binding unless it is in writing and signed by all panties. 6.3 At times, NSL's weatherization team discovers situations in the structure during the course of the Work that indicates a risk for a health or safety concern for residents. Such concerns can include but are not limited to ventilation, potentially hazardous materials such as mold or asbestos, or structural concerns. In the case of health or safety concerns being identified, NSL reserves the right, per section 9.2 of this contract, to communicate concerns to the Customer and halt work until such concerns have been addressed. 6.4 The rebates and incentives available from the Mass Save@ Home Energy Services Program and amounts due from the Customer are based on the best estimate of the situation in the structure by the NSL home energy advisor. However, at times our weatherization team discovers situations in the home during the course of the Work that impact the availability of rebates and incentives from the Mass Save Program. In such situations, NSL will communicate such changes to the Customer, including any impact on amount the Customer would be expected to pay for the Work. The Customer will have the option to remove from the Contract the work elements that need adjustment, or set up a separate contract for performing the adjusted work 6.5 NSL represents and warrants to the Customer that (a) the materials and equipment furnished under this Agreement will be of good quality and new, (b) that the Work will be free from defects, and (c) that the Work will conform with the description of the Work described in Paragraph 1. 6.6 NSL may determine in the course of pre -installation Technical Review that modifications are necessary to the scope of Work in order to ensure professional quality of the installation. In the event of such modifications, NSL will request a written modification of the Agreement to be signed by all parties. In the event that Customer and NSL cannot agree on the modification, the Agreement may be terminated by either party. 7. INSURANCE AND REGISTRATION NSL represents and warrants to the Customer that it has a valid Home Improvement Contractor Registration (No: 162111) and the necessary insurance required by applicable law and normally maintained by prudent contractors in NSL's field, including, but not limited to, Workers Compensation Insurance for all employees who will perfohn the Work. 8. QUALITY OF WORK. NSL agrees that the Work will be performed in a good and workmanlike manner, and that NSL will repair and replace, at its own expense, and promptly upon Customer's request, any defects in workmanship and materials provided by NSL which appear up to one year after completion of the Work or within any longer period as permitted or required under applicable law, provided NSL has received final payment as provided herein. 9. PRE-EXISTING CONDITIONS & PROPERTY PROTECTION 9.1 NSL shall not be responsible for any damages as a consequence of the Work performed in the home due to pre-existing conditions. These conditions include but are not limited to poorly fastened or broken drywall, moisture damage, non -code construction, cracked or fragile siding or shingles, old pipes and fittings, rotting wood, etc. 9.2 NSL reserves the right not to perform Work upon the discovery of asbestos, mold, or any other potential health risk to the Customer. In this event, the Customer is responsible for remedying the at -risk situation, including any necessary removal of hazardous materials and all bills for services to date shall be paid immediately. Work cannot resume until remediation is complete. 9.3 While NSL will make best efforts to protect any property of the Customer, it is the Customer's responsibility to remove or protect, including dust protection, any personal property including the home itself. NSL will not be responsible for damages to or losses of any of the above mentioned property not properly protected prior to the commencement of the Work. 10. GENERAL PROVISIONS. 10.1 NSL reserves the right, the extent permitted by applicable law, to have, file or maintain a mechanic's or material men's lien, or to file a notice of intention to lien, and to take any other steps to perfect and enforce such a lien, if Customer fails to pay NSL as provided herein. 10.2 This Agreement shall be construed in accordance with the laws of the Commonwealth of Massachusetts. 10.3 This Agreement forms the complete integrated agreement between NSL and Customer. The parties represent and warrant that in executing this Agreement, they are not relying on any representations, warranties or terns other than as expressly contained herein. This Agreement supersedes all prior agreements between the Customer and Contractor and may not be altered absent a subsequent written agreement signed by both panties. 11. ENERGY BENEFITS. The Sponsoring Utility Company (the Utility) is entitled to 100% of the energy benefits associated with all Energy Conservation Measures, excluding the value of energy cost savings by the Customer, but including all rights to all associated ISO -NE Energy, Capacity and Reserves Products. NSL agrees to provide the Utility with such further documentation as the Utility may request to confirm the Utility's ownership of such benefits and Products. 12. NOTICE CONCERNING SPONSORSHIP. 12.1 Customer understands and acknowledges that NSL is not an agent, vendor or sub -vendor of The Sponsoring Utility Company (the Utility) with respect to the installation of an energy efficiency measures. In the event of the failure of an energy conservation device to perform as expected, Customer's sole recourse is to Contractor and not to Conservation Services Group (CSG) or to the Utility. The Utility and its operating companies shall not maintain, remove or perform any work whatsoever on the energy conservation measures installed. 12.2 Customer understands and acknowledges that their participation in the Mass Save Home Energy Services Program is voluntary and that they have consented for Contractor to install the proposed energy conservation measures. 12.3 Customer agrees that it shall not hold CSG, the Utility, their affiliates or operating companies liable for Contractors to perform its obligations under this agreement, for failure of the energy conservation measures to function, for any damage to Customer's Premises caused by Contractor or for any and all damages to property or injury to persons caused by the energy conservation measures. 13. LIMITED TIME OFFER. The prices and incentive offered in this Contract are subject to change in accordance with The Sponsoring Utility Company Mass Save Home Energy Services Program offers. 14. CONTRACT CANCELLATION Under Massachusetts law, you may cancel this agreement if it has been signed by a party thereto at a place other than an address of the seller, which may be his main office or a branch thereof, provided you notify the seller In writing at his main office or branch by ordinary mail posted, by fax, or by e-mail sent or by delivery, not later than midnight of the third business day following the signing of this agreement. ....... . . ........ Customer NICQUE Cft!�J� Plainview Diagram Advisor Name:_' 16, Address I.V,(A ftr, D06E Advisor Phone Town e .M ArNmuM., Any limitations to access by truck? Site ID NOTES Any work scoped outside of Best Practices? Approved by: R)s fL W -10 M, WX -a) -r-oornE, Q7Lj CU\WD '(J) INS. 4-Mc,'FL (I,17,00 )1110) L'I 4-0.6c, INS llr+rCy VC -NT ff to toot/ FaftIVIS I QT'1 M Z.3 Gtov 401 2%1 The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street, Suite .100 Boston, MA 02114-2017 kvww.mass.gov1dia Wtilorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Apalicant Information Please Print Legibly Name (Business/Organization/Individual): Next Step Living Address: 21 Drydock Ave City/State/Zip: Boston MA 02210 Phone #: (866)867-8729 Are you an employer? Check the appropriate box: 1. Q I am a employer with 850 employees (full and/or part-time).* 2.❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5.❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.: 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 7. ❑ New construction 8. E] Remodeling 9. ❑ Demolition 10E] Building addition 11.0 Electrical repairs or additions 12. Q Plumbing repairs or additions 13. ❑ Roof repairs 14. [E] Other Weatherization *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: A.I.M Mutual Insurance Company Policy # or Self -ins. Lic. #: AWC-400-7030025 Expiration Date: 9/30/16 Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. A copy of this stat may be forwarded to the Office. of Investigations of the DIA for insurance covera:;e verification. / I do hereby certify under the pains,#fid pAaldes of perjury that the information provided above is true and correct Signature: /�. / yl. Date: 1 0/ L/ LOT Phone #: (866)867-8729 Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: NEXTS-1 OP ID: EL CERTIFICATE OF LIABILITY INSURANCE COVERAGES CERTIFICATE NUMBER: IZFVIsinN NuenRFR• THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. DATE09/30/2015Y) 09/30/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER McLaughlin Insurance Agency 828 Lynn Fells Parkway Melrose, MA 02176 John E. McLaughlin Jr. CONTACT NAME: a/CON o EXt:781-665-2775 FAX No: 781.665-0295 E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Nautilus Insurance Company 17370 ECP2010198-13 INSURED Next Step Living, Inc. M Avenue, 2nd Floor B Boston, Boston, MA 02210 INSURER B: A.I.M. Mutual Insurance Co. INSURER C : Commerce Insurance Company P Y 34754 INSURER D: AXIS U.S. Insurance Company 15610 MED EXP (Any one person) $ 5,000 INSURER E: PERSONAL & ADV INJURY $ 1,000,000 INSURER F: GENERAL AGGREGATE $ 2,000,000 COVERAGES CERTIFICATE NUMBER: IZFVIsinN NuenRFR• THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE L UBRI POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE N OCCUR ECP2010198-13 09/30/2015 09/30/2016 EACH OCCURRENCE $ 1,000,000 PREMISES Ea occurrence $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- JECT LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 $ C AUTOMOBILE X X LIABILITY ANY AUTO ALL OWNED X SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS X AUTOS Comp $1000 X Coll $1000 15MMBGKKDM 09/30/2015 09/30/2016 COMBINED SINGLE LIMIT Ea accident $ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY Per accident $ ( ) PROPERTY DAMAGE Per $ accident $ D UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE ELU783547/01/2015 09/30/2015 09/30/2016 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 DED RETENTION $ $ B WORKERS COMPENSATIONPER AND EMPLOYERS' LIABILITYX ANY PROPRIETOR/PARTNER/EXECUTIVE YF---1/NTO OFFICER/MEMBER EXCLUDED? (Mandatory in NH) if yes, describe under DESCRIPTION OF OPERATIONS below N / A BE ISSUED BY CARRIER 09/30/2015 09/30/2016 OTH- STATUTE ER E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYE $ 500,000 E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) FOR INFORMATION ONLY VCR I Ir i%,m 1 C nuLur-m GANULLLA I IUN INFO -01 FSHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE For Information Only THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Ap— 5�a�� ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD Ate Ofrice "oCWo~nsumer Affai and business regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration NEXT STEP LIVING INC. ROGER OUELLETTE 21 DRYDOCK AVE. 2TH FL BOSTON, MA 02210 09S -CAI 6"p 50V1-Nj04-G101216 .i" office of Consumer Affairs & Business Regulation 7t _ HOME IMPROVEMENT CONTRACTOR Registration: 162111 Type: Expiration: 111412017 Supplement Card NEXT STEP L)VlNG INC. ROGER OUELLETTE 21 DRYDOCK AVE. 2TH FL BOSTON, MA 02210 Undersecretary Registration: 162111 Type: Supplement Card Expiration: 1/14/2017 Update Address and return card. Mark reason for change. r -j Address [:] Renewal � Employment [:] Lost Card License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10Park Plaza - 1, S 4951170 Boston, MA 021il without signature Massachusetts - department of Public Safety Board of Building Regulations and Standards Construction Supertiisor SpeciaitN Lrcense� CSSL-102311 ROGER A ®VELLETTA- 55 STANMORE Warwick RI 02899 bxpi ration Commrssronet 09/13920165 Restricted To: CSSL-OC - insulatlan Contractor Failure to possess a current edition of the Massachusetts State 130ding (Code is cause for revocation of this license. For OPS Licensing information visit: www-Mass-GOO/®P§